NURSING CARE OF PATIENTS RECEIVING CHEMOTHERAPY Ranjita Rajesh Lecturer Peoples College of Nursing Bhopal

Chemotherapy is the use of chemicals to treat disease. Paul Erlich, considered to be the father of chemotherapy, coined this word to describe a specific chemical utilized in the treatment of parasites. Today the term chemotherapy while technically describing drug therapy for any disease , is most frequently used in reference to the treatment of cancer. The simple definition of chemotherapy, although accurate , fails to encompass its multifaceted nature which is as complex as the disease it attempts to treat.

Just as the word cancer represents many different types of malignant disease, the word chemotherapy represents many different types of chemotherapeutic agents. The drugs used in cancer treatment vary in their chemical structure , biological side effects and toxicities. Some are effective in treating one specific types of cancer while others are utilized in the treatment of wide variety of malignancies. The methods of administration also vary according to the chemotherapeutic and new techniques for safer and more effective administration.

The process of learning about chemotherapy is indeed a challenge. Nursing management of the patient receiving chemotherapy requires knowledge about the treatment , skill in assessment, technical expertise, ability and desire to support the client physically and emotionally. The reward in meeting this is to be able to provide the care this clients need in order to survive their disease and its treatment and hopefully to go on with their lives with as few physical and emotional scars as possible.

Nursing care begins with a thorough understanding of the patients condition; goal of therapy , drug dose, route, schedule, administration principles; and potential side effects. Additional nursing management includes monitoring responses to the therapy, reassessing and documenting signs and symptoms, and communicating pertinent information to other members of the health care team.

Chemotherapy is the use of cytotoxic drugs in the treatment of cancer. It is one of the four modalities- surgery, radiation therapy, chemotherapy and biotherapy- that provide cure, control, or palliation. Chemotherapy is systemic as opposed to localized therapy such as surgery & radiation therapy.

There are four ways chemotherapy may be used: 1. Adjuvant therapy- A course of chemotherapy used in conjunction with another treatment modality. 2. Neoadjuvant chemotherapy- Administration of chemotherapy to shrink the tumor prior to surgical removal of the tumor. 3. Primary therapy- The treatment of patients with localized cancer for which there is an alternative but less than completely effective treatment. 4. Induction chemotherapy- The drug therapy is given as the primary treatment for patients with cancer for which no alternative treatment exists. 5. Combination chemotherapy- Administration of two or more chemotherapeutic agents in the treatment of cancer, allowing each medication to enhance the action of the other or act synergistically with it. e.g. MOPP regimen for Hodgkins disease.

ROLE OF A NURSE Prior to chemotherapy administration 1 Review- The chemotherapy drugs prescription which should have -Name of anti-neoplastic agent. -Dosage -Route of administration -Date and time that each agent to be administered. 2. Accurately identify the client 3.Medications to be administered in conjunction with the chemotherapy e.g antiemetics, sedatives etc.

4.. Assess the clients condition including - Most recent report of blood counts including hemoglobin ,hematocrit, white blood cells and platelets. -Presence of any complicating condition which could contraindicate chemotherapeutic agent administration i.e. infection, severe stomatitis , decreased deep tendon reflexes, or bleeding . -Physical status -Level of anxiety -Psychological status.

5. Prepare for potential complications Review the policy and have medication and supplies available for immediate intervention the event of extravasation. Review the procedure and have medication available for possible anaphylaxis 6.Assure accurate preparation of the agent -Accuracy of dosage calculation -Expiry date of the drug to be checked -Procedure for correct reconstitution and -Recommended procedures for administration 7.Assess patients understanding of the chemotherapeutic agents and administration procedures.

II.

Calculation of drug dosage

It is calculated based on body surface area. III. Drug reconstitution/Preparation- Pharmacy staff should reconstitute all drugs pre-prime the intravenous tubing under a class II biologic safety cabinet(BSC). In certain conditions nurses may be required to reconstitute medications. When preparing and reconstituting safe handling guidelines to be followed.

-All chemotherapeutic drug should be prepared according to package insert in class II BSC. -Aseptic technique should be followed. -Personal protective equipment includes disposable surgical gloves, long sleeves gown and elastic or knit cuffs. -Protective eye goggles if no BSC -To minimize exposure -Wash hands before and after drug handling. -Limit access to drug preparation area

-Keep labeled drug spill kit near preparation area. -Apply gloves before drug handling. -Open drug vials/ ampoules away from body. -Place absorbent pad on work surface. -Wrap alcohol wipe around neck of ampoule before opening. -Cover tip of needle with sterilize gauge when expelling air from syringe. -Label all chemotherapeutic drugs. Clean up any spill immediately

IV. Drug administration 1. Routei)Oral - Emphasize the importance of compliance by the patient with prescribed schedule.Drugs with emetic potential should be taken with meals. Assure that chemotherapeutic agents are stored as directed by the manufacturer(refrigerate, avoid exposure to direct light,etc). ii) Intramuscular and subcutaenous Chemotherapeutic agents that can be administered I/M or subcutaneously are few in number. Non-vesicants like L-asperaginase, bleomycin, cyclophosphamide, methotraxate. Cyta arabine,and some hormonal agents are given I/M & /Or subcutaneously.

-Use the smallest gauge needle possible for the

viscosity of the medication. -Change the needle after withdrawing the agent from a vial or ampoule. -Select a site with adequate muscle and/or SC tissue. iii) Intravenous It is the most common method of administration of cancer chemotherapy. May be given through central venous catheters or peripheral access. Absorption is more reliable. This route is required for administration of vesicants and it also reduces the need of repeated injection. Because the I/V provides direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious complication of I/V chemotherapy.

The following guidelines to be kept in mind: -Inspect the solution, container and tubing for signs of contamination including particles, discoloration, cloudiness, and cracks or tears in bottle or bag -Aseptic technique to be followed -Prepare medicines according to manufacturers directions -Select a suitable vein -Large veins on the forearm are the preferred site. -Use distal veins first, and choose a vein above areas of flexion. -For non-vesicant drugs, use the distal veins of the hands (metacarpal veins): then the veins of the forearms(basilic and cephalic veins)

-For vesicants, use only the veins of the forearms. Avoid using the metacarpal and radial areas. -Avoid the antecubital fossa and the wrist because an extravasation in these areas can destroy nerves and tendons, resulting in loss of function. -Peripheral sites should be changed daily before administration of vesicants -Avoid the use of small lumen veins to prevent damage due to friction and the decreased ability to dilute acidic drugs and solutions. Select the shortest catheter with the smallest gauge appropriate for the type and duration of the infusion (21g to 25g for I/V medications and 19 g for blood products).

-Avoid a vein which has been used for venous

access within the past 24 hrs to prevent leakage from a prior puncture site. Prevent trauma and infection at the insertion site. -Apply a small amount of iodine based antiseptic ointment over the insertion site & cover the area with sterile gauze. Intravenous Chemotherapy Via Central Vein Infusion (Hickman Catheter)

A Hickman catheter is a flexible polymeric silicon rubber catheter which is threaded through the cephalic vein and into the superior vena cava or through the venacava and into the right atrium of the heart. Placement in a large vein permits the use of a catheter large enough for infusion of chemotherapy, hyper osmolar fluids for nutrition purposes, blood products and other needed intravenous fluids.

The silicon rubber material of catheter is chemically inert to prevent decomposition and it is anti-thrombogenic A felt cuff near the exit site anchors the catheter on the patients chest and acts as an anatomic barrier to prevent entry of infection causing agents. It is either single lumen or double-lumen. IV) Intra-arterial V)Intra-peritoneal

VI)Intrathecal- Infusion of medication can be given

through an Ommaya reservoir, implantable pump and /or usually through lumbar puncture. a)Wear protective equipment (gloves, gown and eyewear). b)Inform the patient that chemotherapeutic drugs are harmful to normal cells and that protective measures used by personnel minimize their exposure to these drugs. c)Administer drugs in a safe and unhurried environment.

d)Place a plastic backed absorbent pad under the tubing during administration to catch any leakage. Do not dispose of any supplies or unused drugs in patient care areas. V. Documentation Record -chemotherapeutic drugs, dose, route ,and time -Premedications, postmedications, prehydration and other infusions and supplies used for chemotherapy regimen. -Any complaints by the patient of discomfort and symptoms experienced before, during, and after chemotherapeutic infusion.

VI. Disposal of supplies and unused drugs a)Do not clip or recap needles or break syringes. b)Place all supplies used intact in a leak proof ,puncture proof, appropriate labeled container. c)Place all unused drugs in containers in a leak proof, puncture proof, appropriately labeled container. d)Dispose of containers filled with chemotherapeutic supplies and unused drugs in accordance with regulations of hazardous wastes.

VII. Management of chemotherapeutic spills Chemotherapy spills should be cleaned up immediately by properly protected personnel trained in the appropriate procedure. A spill should be identified with a warning sign so that other person will not be contaminated.

Supplies Required

Chemotherapy spill kit contains Respirator mask for air borne powder spills Plastic safety glasses or goggles Heavy duty rubber gloves Absorbent pads to contain liquid spills Absorbent towels for clean up after spills Small scoop to collect glass fragments Two large waste disposal bags

Protective disposable gown Containers of detergent solution and clear tap water for post spill clean up. Puncture proof and leak proof container approved for chemotherapy waste disposal Approved, specially labeled, impervious laundry bag. Spill on hard surface Restrict area of spill Obtain drug spill kit Put on protective gown, gloves, goggles Open waste disposal bags Place absorbent pads gently on the spill; be careful not to touch spill.

Spill on hard surface Restrict area of spill Obtain drug spill kit Put on protective gown, gloves, goggles Open waste disposal bags Place absorbent pads gently on the spill; be careful not to touch spill.

Place absorbent pad in waste bag Cleanse surface with absorbent towels using detergent solution and wipe clean with clean tap water. Place all contaminated materials in the bag. Wash hands thoroughly with soap and water.

Spill on personnel or patient Restrict area of spill Obtain drug spill kit Immediately remove contaminated protective garments or linen Wash affected skin area with soap and water If eye exposure-immediately flood the affected eye with water for at least 5 mts; obtain medical attention promptly Notify the physician if drug spills on patient. Documentation- Document the spill.

VIII. Staff Education All personnel involved in the care should receive an orientation to chemo. Drugs including their known risk , relevant techniques and procedures for handling, the proper use of protective equipment and materials, spill procedures, and medical policies covering personnel handling chemo. agents. Personnel handling blood, vomitus, or excreta from patients who have received chemotherapy should wear disposable gloves and gowns to be appropriately discarded after use.

IX. Extravasation management Extravasation is the accidental infiltration of vesicant or irritant chemotherapeutic drugs from the vein into the surrounding tissues at the I/V site. A vesicant is an agent that can produce a blister and /or tissue destruction. An irritant is an agent that is capable of producing venous pain at the site of and along the vein with or without an inflammatory reaction. Injuries that may occur as a result of extravasation include sloughing of tissue , infection, pain ,and loss of mobility of an extremity.

1.Prevention of extravasation
Nursing responsibilities for the prevention of extravasation include the following Knowledge of drug s with vesicant potential Skill in drug administration Identification of risk factors e.g. multiple vene punctures Anticipation of extravasation and knowledge of management protocol New venepuncture site daily if peripheral access is used

Central venous access for 24 hrs vesicants infusion Administration of drug in a quiet, unhurried environment Testing vein patency without using chemotherapeutic agents Providing adequate drug dilution Careful observation of access site and extremity throughout the procedure Ensuring blood return from I/V site before, during, and after vesicant drug infusion. Educating patients regarding symptoms of drug infiltration , e.g. pain, burning, stinging sensation at I/V site.

2.Extravasation management at peripheral

site-According to agency policy and approved antidote should be readily available. The following procedure should be initiatedStop the drug Leave the needle or catheter in place Aspirate any residual drug and blood in the I/V tubing, needle or catheter, and suspected infiltration site Instill the I/V antidote Remove the needle

If unable to aspirate the residual drug from the IV tubing , remove needle or catheter Inject the antidote sub-cutaneously clockwise into the infiltrated site using 25 gauge needle; change the needle with each new injection Avoid applying pressure to the suspected infiltration site Apply topical ointment if ordered Cover lightly with an occlusive sterile dressing Apply cold or warm compresses as indicated Elevate the extremity Observe regularly for pain, erythema, induration, and necrosis Documentation of extravasation management. All nursing personnel should be alert and prepared for the possible complication of anaphylaxis.

X. Nursing Management of common side effects of Chemotherapeutic drugs.

.Nausea & Vomiting Nausea is the conscious recognition of the subconscious excitation of an area of the medulla closely associated with or part of the vomiting center. Nausea may cause the desire to vomit & it often precedes or accompanies vomiting.

Avoid eating/drinking for 1-2 hrs prior to and after chemotherapy administration Eat frequent, small meals. Avoid greasy & fatty foods and very sweet foods & candies. Avoid unpleasant sights, odors & testes Follow a clear liquid diet If vomiting is severe inform the physician. Consider diversionary activities

Sip liquids slowly or suck ice cubes and avoid drinking a large volume of water if vomiting is present Administer antiemetics to prevent or minimize nausea. Patient may require routine antiemetics for 3-5 days following some protocols. Monitor fluid and electrolyte status. Provide frequent, systemic mouth care.

.Bone marrow Depression This can lead to -Anaemia -Bleeding due to thrombocytopenia -Infection due to leukopenia Nursing Actions Administer packed RBC according to the physician orders. Monitor hematocrit and haemoglobin especially during drug nadir Maintain the integrity of the skin

Avoid activities with the greatest potential for physical injury Use an electric razor when shaving Avoid the use of tourniquets Eat a soft, bland diet, avoid foods that are thermally, mechanically and chemically irritating. Maintain the integrity of the mucous membranes of G I tract Promote hydrate to avoid constipation Avoid enemas, harsh laxatives & the use of rectal thermometers. Take steroids with an antacid or milk.

Avoid sources of infection Maintain good personal hygiene. Prevent trauma to skin & mucous membranes Report s/s of infection to physician Monitor counts Avoid invasive procedures, no Raise the arm while pressure is applied after removal of a needle or catheter

.Alopecia
Explain hair loss is temporary, and hair will grow when drug is stopped. Use a mild, protein based shampoo, hair conditioner every 4-7 days Minimize the use of an electric dyer. Avoid excessive brushing and combing of the air. Combing with a wide tooth comb is preferred. Select wig, cap, scarf or turban before hair loss occurs. Keep head covered in summer to prevent sunburn and in winter to prevent heat loss.

Fatigue - Assess for possible causes chronic pain, stress, depression and in-sufficient rest or nutritional intake. -Conserve energy & rest when tired -Plan for gradual accommodation of activities. -Monitor dietary & fluid intake daily. Drink 3000 ml of fluid daily, unless contra-indicated, in order to avoid the accumulation of cellular waste products.

Anorexia
Freshen up before meals Avoid drinking fluids with meals to prevent feeling of fullness High protein diet Monitor and record weight weekly. Report weight loss

Stomatitis (Oral)
-Symptoms occur 5-7 days after chemotherapy & persist upto 10 days -Continue brushing regularly with soft tooth brush -Use non irritant mouthwash -Avoid irritants to the mouth -Maintain good nutritional intake, eat soft or liquid foods high in protein

-Follow prescribed medication schedule e.g. drug for oral candidiasis. -Report physician if symptom persists -Increase the frequency of oral hygiene every 2 hrs -Glycerin & lemon juice should never be used to clear mouth or teeth as it cause the tissues to become dry& irritated.

Diarrhoea - Some clients experience diarrhoea during and after treatment with chemotherapy. Nursing Action Monitor number, frequency and consistency of diarrhoea stools. Avoid eating high roughage, greasy and spicy food alcoholic beverages, tobacco and caffeine products Avoid using milk products Eat low residue diet high in protein and calories

Include food high in potassium if fatigue is present like bananas, baked potatoes. Drink 3000 ml of fluid each day. Eat small frequent meals ; eat slowly and chew all food thoroughly Clean metal area after each bowel movement. Administer anti-diarrhoeal agents as prescribed.

.Depression
Assess for changes in mood and affect. Set small goals that are achievable daily Participate e.g. music, reading, outings Share feelings Reassurance

.CystitisIs an inflammation of the bladder, which is usually caused by an infection. Sterile cystitis not induced by infection. Sterile cystitis not induced by infection, can be a side effect of radiation therapy or due to cyclophosphamide (endoxan) administration. The metabolites of cyclophosphamide are excreted by the kidneys in the urine

Nursing Actions Fluid intake at least 3000 ml daily Empty Bladder as soon as the urge to void is experienced. Empty bladder at least every 2-4 hrs. Urinate at bed time to avoid prolonged exposure of the bladder wall to the effects of cytoxan while sleeping.

Take oral cytoxan early in the morning to decrease the drug concentration in the bladder during the night Report increasing symptoms of frequency bleeding burning on urination, pain fever and chills promptly to physician Following comfort measures can be adopted if cystitis is present -Ensure dilute urine by increasing the fluid intake Avoid foods & beverages that may cause irritation to the bladder alcohol, coffee, strong tea, Carbonated beverages etc.

Outpatient Chemotherapy Delivery Aggressive, complex and sophisticated cancer therapies are currently being in ambulatory & home care settings. This shift is provision of services from the Hospital setting is a result o cost-containment efforts, advanced technology, competition & increased competence of nurses.

Conclusion Chemotherapy offers

patients with cancer a great deal of hope for a cure or a means of control cancer for a long period of time. Hope and optimism are vital ingredients in care plan.